Healthcare providers, such as pharmacies, physicians, and/or hospitals, often generate healthcare transactions, such as healthcare claim transactions that are communicated to appropriate claims processors or payers, such as insurance providers or government payers, for approval. Subsequent to the approval of a healthcare transaction, a claims processor or a third-party may audit the transaction in order to determine whether the transaction satisfies the requirements of various state, federal, and/or third-party protocols. If a discrepancy is identified during the audit, then the healthcare provider is typically presented with a charge-back for the healthcare transaction or a demand to submit a corrected version of the healthcare transaction to avoid a charge-back.
Recently, auditing of healthcare transactions has experienced significant growth, leading to an increase in, expenses on the part of healthcare providers in order to identify and correct the problems or discrepancies leading to charge-backs or demands to resubmit healthcare transactions. It is typically time consuming and relatively expensive for a healthcare provider to identify an area for improvement during the generation of healthcare transactions in order to avoid negative audit results.
Therefore, systems and methods for generating edits for healthcare transactions to address billing discrepancies are desirable.